DAIC July-August 2011

In a move that will likely have a significant impact on how many patients are treated for carotid artery disease, the U.S. Food and Drug Administration (FDA) in May cleared the use of a stent to treat standard-risk surgical patients. Prior to this approval, carotid stenting was only indicated for use in high-risk surgical patients who were often denied the standard-of-care of carotid endarterectomy surgery. The decision to expand the indication for the Abbott RX Acculink carotid stent system is expected to have a major impact, offering patients the option of minimally invasive stenting rather than open surgery, which often leaves scars on the patient’s neck.

Carotid stenting is a more complex and challenging procedure than coronaries or peripheral vessels. Carotid stenting experts have the following advice for hospitals and physicians that want to enter this market.

These are some of the top cardiology technology news items from the spring and early summer 2011. As part of its efforts to expand integration of intravascular ultrasound (IVUS) image guidance with cath lab treatment devices, Volcano Corp. recently announced a supply agreement with ev3, a Covidien company. Volcano will supply its IVUS technology for use in ev3’s TurboHawk plaque excision (atherectomy) systems.

Hypothermia for out-of-hospital and in hospital cardiac arrest has been demonstrated to have significant survival and neurologic benefits. While the data supporting its use in the cardiac cath lab is limited and the number of patients where this protocol would be potentially useful is small – STEMI patients surviving cardiac arrest with persistent comatose state after ROSC – the potential benefit to our patients is extremely high and in our opinion well worth the effort.

Catheter-based intra-cardiac echocardiography (ICE) is an imaging modality similar to intra-vascular ultrasound (IVUS). It allows imaging inside the heart to visualize cardiac structures and blood flow using Doppler imaging. The standard-of-care for this type of imaging is usually transesophageal echo (TEE), but ICE proponents say the intra-cardiac modality has several advantages.

Navigating through the world of coronary stents is about to become more complex. A plethora of new products are on the horizon, which will utilize new platforms and alloys and present novel options in polymer technology. Whilst most of the new stents will upgrade the platform and polymer, the choice of drug is not changing in most cases. This new generation of drug-eluting stents (DES) promises increased deliverability and radial strength in the platform. New polymers will minimize the concerns around late stent thrombosis (LST) and the need for long-term dual antiplatelet therapy (DAPT). A bioresorbable drug-eluting scaffold also may be game changer in the treatment of coronary artery disease.

A drug-eluting, self-expanding stent that does not use a drug-carrier polymer is before the U.S. Food and Drug Administration (FDA) final pre-market approval (PMA) review and a decision is expected later this year. Its chances of approval appear very bright, considering its positive clinical trial data to date.

In recent years, advanced visualization has also become more accessible and prevalent. What used to be a niche technology, available only on dedicated and expensive workstations, has become very common. The software is now included in most workstations and multi-site picture archiving and communications systems (PACS).

Transradial catheterization is increasingly becoming the access site of choice for many hospitals throughout the United States. Completing the procedure through the arm offers greater satisfaction for the patient as a result of increased comfort and patient mobility compared to femoral artery access. Radial artery access for cardiac catheterization is associated with a different set of complications and although infrequent, they present a challenge to cath lab staff to manage and prevent these issues as they appear. Education about the benefits and challenges of transradial catheterization is an important tool to nurses and technologists as they transition to cardiac catheterization through the wrist. This article will discuss patient satisfaction of radial versus femoral artery access and two of the most prevalent complications of transradial catheterization.

Swedish SCAAR Registry data were presented in May during the EuroPCR meeting in Paris. The 30-day ST-elevated myocardial infarction (STEMI) mortality was 4.4% in the femoral access group vs. 3.2% in the radial access group (adjusted odds ratio 0.57, p<0.01). The benefit of radial approach was present at one year as well (7.3% femoral vs. 6.2% radial mortality, adjusted OR 0.78, p=0.018).

Digging through boxes, waiting for couriers, finding smashed VHS tapes in the mail, jockeying back and forth between multiple modalities. Like at other hospitals across the country, the manual, tape- and film-based workflow in the pediatric cardiology department at Mercy Children’s Hospital in Toledo, Ohio, had stagnated, quadrupling the time it should have taken the cardiologists to read echocardiograms for the hospital and four outreach centers, resulting in a report turnaround time that could be as long as five to seven days.

Coronary revascularization does not always lead to coronary reperfusion. When readily available, percutaneous coronary intervention (PCI) using primary balloon angioplasty, with or without use of stenting, is the standard of care for ST-segment elevation myocardial infarction (STEMI). However, there is a group of patients who seem not to benefit fully from prompt restoration of antegrade flow, as they fail to show resolution of the indirect signs of ischemia such as electrocardiographic (ECG) changes and improvements in perfusion abnormalities.[1,2] These patients also present an angiographic phenomenon characterized by evidence of slow-flow in the affected vessel (Thrombolysis in Myocardial Infarction [TIMI] flow equal to or less than 2) and lack of contrast uptake “blush” by the subtended myocardium, leading to a potential dissociation between coronary revascularization and myocardial perfusion in STEMI.